Category: Federal Forum Posters
Purpose: Despite guideline recommendations against antipsychotic polypharmacy, patients may be prescribed more than one antipsychotic for failure of all other treatment options. The purpose of this medication use evaluation is to identify these patients and determine provider’s rationale for antipsychotic polypharmacy. A medication use evaluation assessing prescribing patterns associated with antipsychotic polypharmacy has not been conducted at the Iowa City Veterans Affairs Health Care System (ICVAHCS). This retrospective chart review will help elucidate areas for improvement in prescribing patterns in an effort to decrease antipsychotic polypharmacy and identify which patients meet Veterans Affairs (VA) criteria for an offer of clozapine therapy.
Methods: This quality improvement project was approved by the institutional review board and was conducted by a retrospective chart review. Patients within the ICVAHCS that were prescribed more than one scheduled antipsychotic between January 10, 2018 through July 10, 2018 were reviewed. Data was collected from the local VA Computerized Patient Record System (CPRS) electronic medical record. The variables that were collected included: demographic information, medication, dose, indication for use, prescriber type, rationale for polypharmacy, monitoring information, current and previous antipsychotic use, and history of clozapine therapy. All 42 patients who were prescribed more than one scheduled antipsychotic during this time frame were reviewed. The data were collected to show trends in patient characteristics, prescribing, documentation, and monitoring practices.
Results: Of the 42 patients reviewed, most common diagnoses for antipsychotic polypharmacy were schizophrenia (36.5 percent) and schizoaffective disorder (25.9 percent). All patients reviewed were prescribed two antipsychotics, except one prescribed triple therapy. Dual atypical therapy accounted for 66.7 percent of polypharmacy and atypical/typical for 33.3 percent. About 26 percent of patients were prescribed polypharmacy for a diagnosis other than Food and Drug Administration (FDA) approved indications. Common “other” diagnoses included psychosis, dementia with psychosis, traumatic brain injury, or mood disorder. Reasons for polypharmacy included refractory symptoms on monotherapy (26.2 percent), maximum dose of one antipsychotic not controlling symptoms (19 percent), continuation of therapy (14.3 percent), balancing adverse effects (9.5 percent), and incomplete cross-taper (7.1 percent). About 10 percent of patients had antipsychotic prescriptions above FDA recommended doses and about 17 percent of patients had prescriptions at the FDA recommended dose maximum. While over 67 percent of patients had more than two antipsychotic trials at an adequate dose and duration, only 19 percent of patients prescribed polypharmacy were documented to be offered clozapine. Based on prespecified criteria, 19 percent of patients were potential clozapine candidates. Fifty percent had updated Abnormal Involuntary Movement Scale (AIMS) assessments; 90 percent had updated metabolic monitoring.
Conclusion: Results of this study demonstrate a role for pharmacy-focused initiatives in antipsychotic prescribing practices to improve documentation, safety, and monitoring. No patients were prescribed dual antipsychotic therapy specifically for the reason of “failure of all other treatment options”, which according to guidelines, is when antipsychotic polypharmacy should be considered. Education about the role of clozapine therapy could improve antipsychotic polypharmacy. Patients who are candidates for clozapine therapy have been identified and will be reviewed by a Mental Health Pharmacist as a result of this study. Overall, antipsychotic polypharmacy has the potential to be reduced and documentation of rationale needs improved.
Chelsea Khaw– PGY2 Psychiatric Pharmacy Resident, Iowa City Veterans Affairs Health Care System, Coralville, IA